28 May 2012

Aniello Iannuzzi: Time to pack a punch

RECENTLY, I came across interesting trench warfare in a report about the Pharmacy Guild of Australia.

“… the Guild has again attacked the Consumers Health Forum of Australia [CHF] for daring to question any of its practices … CHF has been targeted for saying the Guild should ‘concentrate on serving the best interests of Australian consumers rather than pharmacists’ profits’ ”, the report said.

Regardless of what you think about this skirmish, few would argue the Pharmacy Guild packs a much harder punch for its members than the AMA.

They have protected ownership of pharmacies. They resist supermarkets buying pharmacies while making supermarkets of pharmacies. Pharmacists are allowed to advise and dispense but doctors are not. They can also make large profits on dispensing scripts while the doctor takes the responsibility and blame when things go wrong.

As the weekend’s AMA National Conference has just been in the spotlight, I asked myself how the Guild stays so powerful while the AMA appears to have lost its bite.

So I did some detective work.

The most obvious problem for the AMA is membership, which currently stands at about 26 500 of the 88 293 medical practitioners registered with Australian Health Practitioner Regulation Agency (2010-11 annual report). By my calculation from the publicly available information, this means that about 70% of doctors in Australia are not in the AMA.

The Optometrists Association Australia enjoys membership of about 93% of registered optometrists (2010-11 annual report). The Australian Dental Association’s annual report shows a membership rate of about 13 000, which is around 60% of dentists. In NSW, about 92% of active solicitors are in The Law Society of NSW.

So can it really surprise any of us when government disregards the views of the AMA? Or that the government consults a broad range of medical organisations for advice or to populate its committees?

Given membership is so low, it seems fair for the government to go beyond the AMA for representation of doctors, allowing it to adopt a “divide and conquer” strategy when it suits.

I have been an AMA member since I was a medical student and have always found the services and representation of great benefit. When I served on AMA committees, it was always frustrating to see the investment of membership money go to work for the benefit of 100% of doctors when only 30% of doctors were paying.

When I talk to AMA non-members about why they do not join the AMA, the most common answers are:

Do not see value for money

What has the AMA ever done for me?

No say in policy

Feel the AMA doesn’t represent me

Someone else in my practice/hospital is a member, so if there’s a problem, we get the benefits anyway

Value only comes with using services and by weight of membership numbers to create economies of scale.

The behind-the-scenes work done by the AMA would fill a thick book, but if you are not a member you can’t appreciate it fully.

The perception of doctors not having a say and not feeling represented is something that the AMA can and should look at urgently. Voting for senior office bearers at the National Conference is done via a delegate system dictated by the states and craft groups. Just as in any union or political party, factions develop, and the number crunchers rule the day.

It would be a big step forward to allow grassroots members more say about who leads the AMA — if they felt they would be more included, more would join.

The constitutional formulae that dictate membership of boards and councils (state and federal) are often outdated. For example, it is possible to not have a single rural doctor member on the AMA Federal Council or not a single GP on the federal executive.

Doctors-in-training make up more than 20% of AMA membership, but they are under-represented on councils and committees. Some would argue that this is prudent; others say it is undemocratic.

It is a debate we have to have rather than allow more splinter groups to develop.

And the same goes for women. About 38% of registered doctors are female, and this percentage grows annually. However, less than 10% of the Federal Council is female.

On state AMA councils and boards, Queensland has the best female representation, with 3 out of 8 board members. The other states lag well behind.

For the AMA to once again be strong it has to re-connect with doctors. Membership will follow, and then it can tackle government with greater credibility and voice.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Dr Iannuzzi is a member of the AMA and was previously on NSW Council and the federal AMA Council of General Practice. He is a member of the Australian Doctors Fund and on its board of directors. He is also a member of the Dubbo/Plains Division of General Practice, the Rural Doctors Association of Australia, the Australian College of Rural and Remote Medicine, the Royal Australian College of General Practitioners, and the Remote Vocational Training Scheme.

Posted 28 May 2012

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31 thoughts on “Aniello Iannuzzi: Time to pack a punch”

I totally and utterly agree with Dr Ianuzzi. It is the time to unite the medical workforce, be OMGs, doctors in training or otherwise. We need to stand up to this politicaly motivated self-interested lobby groups to show up the power of true professionals.
Time has come for the AMA to stand up to the task to rev up its membership numbers in the near future.
AMA councillor NSW

There is never a time when AMA members should not be recruiting their colleagues who benefit from the AMA’s activities, and that is all of them. At a state level as well as federally, there is no other “go-to” body representing doctors other than the AMA.
Members should be provided with a recruiting package (hard copy as well as online) so that the benefits of membership can be easily discussed in the tea room, the office or the corridor.
States can organise a system whereby all hospitals, the political arms of the specialties and GP groups can be targeted

The AMA needs to try to fairly represent doctors from all specialties, not just the major ones. When eye surgeons were threatened with a rebate cut for cataract surgery, the AMA lobbied hard to help. Yet in my specialty, sports medicine, our patients received rebate cuts of up to 30% in 2010 when we were finally recognised as specialists. http://www.smh.com.au/business/medicare-rebate-cut-adds-insult-to-injury… A similar issue has occurred with addiction medicine and sexual health. If the AMA doesn’t publicly lobby on behalf of minor specialties, it comes across as being only interested in the larger groups of doctors and it can’t be surprised if few doctors from the emerging specialties become members.

The AMA would have a far bigger membership if it was more involved with protecting the medical profession from the depredations of various degrees of malign management, both from hospitals and boards. As it is, a practitioner in trouble is left very much to their own resources which may or may not (usually the latter) include sincerely caring colleagues.
Why is there no national support body for traumatised and “at-risk” medical practitioners?
Why does the AMA not interest itself in the many, variously egregious and doubtful “politically motivated” decisions?
Address these deficiencies and there might be more members.

I had no idea that membership of the AMA had fallen so low. I had been a member since I was a student and a combination of taking a staff specialist position, represented by ASMOF, and no money led to my reluctant resignation.
It used to be said that the AMA represents ALL doctors but only a few are financial members.
The fees are too high and the bureaucracy is too big. We need to trim the fat and make a more affordable fee structure.

Law societies are regulated by law. Medical societies are not. Thus comparison is not helpful. AMA always releases tepid motherhood statements usually not related to direct mainstream daily practice of the profession. The AMA is reactive not active as reported in the media. The other bodies forcefully represent their members. The national registration is a case in point. The legal national registration will be more sensible – the states will retain control but the data centre will be national. Medically the states ceded all their power and revenue stream to the Commonwealth. Now that there are changed governments in the states, the AMA could start by efforts to remedy the defect – at least that way could begin to represent the interests of both the profession and the nation against bureaucratic malignancy that arose while the polies were asleep.

Really interesting stuff and I wonder if the federal board is aware of the disquiet amongst doctors regarding its representation of the medical profession? I too went to the AMA conference and AM NOT a member of council so I paid the enormous fee to attend because I love my profession (general practice). There seems to be a disconnect between what the AMA believes it is doing for all doctors (members or not) and the PERCEPTIONs (correct or not) of the wider 70% of doctors not involved with the AMA. If I had known you were there Dr Iannuzi I would have collared you and stood on my soap box about this issue. I was otherwise having similar conversations with others who were attending.
The AMA needs a brisk wind through it and a shake up in its marketing to the wider doctor community. There ARE obviously great programs and public health initiatives going on and some very dedicated doctors working voluntarily for the greater good of the profession BUT this is not being seen by the rest of the medical community. I indicated that the cost for a part-time female GP is PROHIBITIVE despite the reduction in fees. Consider the % equivalence of $7000 for a urologist. In the UK membership of the BMA reportedly is 200 pounds and the NZ medical association is around $200. Have the federal council lost touch with the lowest paid members of the medical profession? It would seem so given I was one of the few female GPs who attended. Remembering that 60% of graduates are now women I wonder if things need to change? Equality really seems to stop dead with the arrival of children for women doctors although I suspect for the new generation of male doctors the family will become a bigger consideration compared with the working practices of old. I will be working hard to promote the aspirations of doctors as how else can we advocate for our patients? But without a voice, and without representative organisations the governement will most surely disregard the organisation and divide and conquer. This will not be good for the profession and especially not good for our patients.
When I asked one of the federal councillors about this issue I was told that they must represent the membership they have. I believe this is short sighted and rigid thinking when what they need is a great lateral view and creative innovation with regard to its membership. Thank you for this article Dr Iannuzzi. Maybe we can meet at the next conference? ( Soap box away for the moment)

Instead of resisting the intrusion of government into private practice, the AMA actively colluded with the government when Medicare was introduced. They have been completely ineffective in opposing further intrusions into general practice in particular. As the fees are so high, I wonder that anybody bothers to subscribe. I will never join unless there is a radical shift in policy.

I am an AMA member and Fellow of ACRRM and the FAChAM (RACP). My perception is AMA has over a long period of time supported the massive divide in income, status, rights and work conditions, between the procedural specialists (as evidenced by the whole hearted fight mentioned above for the opthalmologists) versus the GPs and non-procedural cognitive specialists (who gave up and joined ASMOF to see eight patients a week and go conferencing). The majority of the Australian medical work load is chronic illness, but doctors who provide treatment to the chronically ill are the least renumerated and most audited. Examples include the PSRs preoccupation with auditing GPs who have a rare good pay day, and the lack of useful addiction medicine specialist rebates. The AMA is notable by its absence in helping the “unglamorous doctors”.

Organising doctors politically is like herding cats. The AMA’s umbrella structure can’t hope to perfectly represent every medical group. It therefore cannot be effective without a large measure of generosity and give and take that gives priority to shared professional values over sectional interests. The perennial problem for the AMA has been the insularity, self-interest and, dare I say it, mean spirit of a critical minority of the profession. If you don’t like the AMA, then your professional responsibility is to be a member and change it from within. Doctors will wake up to the error of their ways when, in the immortal words of Big Yellow Taxi, “Don’t it always seem to go
That you don’t know what you’ve got till it’s gone”

I have been an AMA member for over 30 years but have become very concerned with the way it has represented its members in recent times. It is not prepared to fight for the profession – it may criticize a government or bureaucraytic desision, but if its arguments are ignored, the issue is allowed to disappear from view without any actual action being taken.
I am also extremely annoyed at the way a few AMA leaders decide that their personal political views are indicative of those of the membership as a whole. A good example was the recent criticism by the Federal President of the 150 prominent medicos who expressed a certain point oof view, based on academic studies, on the benefits to children of having both a male and a female as their parents. Their point of view was supported by academic studies and they have a right to express their opinion, yet the AMA President was critical of them and implied that their point of view was not supported by the AMA membership.
If the AMA continues to push the politically correct line all the time and not actively fight the government on important issues such as the patient-controlled electronic health records (which should clearly NOT be patient controlled), I will seriously reconsider my ongoing membership.

I am a retired surgical assistant, and a long time member of the AMA. I believe it provides excellent value in terms of services and lobbying for doctors in difficult times, but it does have a long way to go in terms of representing all Australian doctors. I think the craft group system is very outdated. There are many doctors these days who do not fit into the neat craft groups of previous times and they are disenfranchised when it comes to voting and representation in the AMA councils. Surgical assistants; doctors in special interest practices such as refugee health; men’s and women’s health; cosmetic and skin clinics; travel health; disability and many other fields are not specifically GPs, physicians or surgeons, but deserve to be recognised as part of the profession. Others work in more than one field e.g. a surgical assistant may also be a GP, retired surgeon, skin clinic practitioner or women’s health practitioner. The AMA needs to wake up and widen its scope to include everyone.

The comparison of the AMA with the Pharmacy Guild is not valid. The Pharmacy Guild only represents pharmacists who own pharmacies. There are approximately 5000 pharmacies in Australia but over 25000 pharmacists. Thus the majority of pharmacists are employees. The Award salary for employed pharmacists is approximately $25 per hour, though many are paid above Award but generally about $35 to $40 per hour maximum. Also, there have been a record number of pharmacy bankruptcies since the 5th Community Pharmacy Agreement. Doctors are very fortunate to have the AMA as an umbrella body which represents all doctors. Medicine is far more diverse than pharmacy hence the perceptions that doctors are not well represented. I say count your blessing, renew your AMA membership and support the medical profession. I think the pharmacy profession could learn something from the AMA.

The AMA is inept, bureaucratic, unresponsive, and incedibly over-priced. Dr Iannuzzi pointed this out in the article having been told so by people he asks. Yet then chose to continue on about irrelevant issues. This proves the point IMHO and is the very reason why membership is poor. The AMA seems to have its own agenda and views and is now institutionalised enough that membership views just cant get through. An example of poor value – I reluctantly rejoined the AMA (having left because they truly botched a workplace action) thinking there may be resources to help with entering private practice, only to find that on top of the extortionist joining fee, I had to pay even more to access these resources. This is just one of the many examples of the poor value and poor service. Dont get me started on those ridiculous, fake member benefits – its cheaper to rent the same car at normal rates through Budget than a member discounted rate through Hertz! The reasons are there, you just have to want to hear them. More power to the medical profession, but perhaps not through AMA in its present form.

Spot on Nello. More than ever I stand back and see the medical profession being nationalised by stealth. I read of 80% bulk billing – how can GPs expect to make a living doing that? There is health reform which is aggressively undermining the role of medical practitioners as professionals and the natural leaders of health services.
This would not have happened 20 years ago. There would have been war. What is important is not so much undermining the role of medical practitioners but that Australians are being short-changed by poorly trained substitute providers and overall decreasing standards of clinical competency and care across the board. If medical practitioners dug their heels in and said some aspects of this health reform are not going to be supported – it would not get off the ground.
I’m for a more militant approach in support of a health system which is not micromanaged by the swelling ranks of managers rather than carers.

We need to increase representation dramatically. Consider lesser fees but larger membership overall (most members do not cost much at all). Increase representation of junior doctors when in hospital positions where they benefit from salary and conditions which are AMA fought and won. Then keep them in the fold afterwards.

When I came to this country some 20 yrs ago I joined the AMA.
I have been a naturalised Australian for more than 18 years but stll have a foreign accent. Hundreds of specialists like myself provide an important and vital role to our healthcare system. Despite this, I stll feel that the local press is very anti-foreign doctor. The AMA has done little
or nothing to defend us or our role and in my opinion enjoys “bashing” foreign-trained doctors, including fully registered specialists like myself.
We all get tarred with the same brush despite most cases of medical negligence actually resulting from Australian-trained doctors. As a result of this, I resigned in disgust from the AMA and don’t blame any other competent professional from doing the same.
Angry, disappointed and disgruntled at your xenophobic organisation.

I spoke to two medical professionals recently, one Melbourne GP and a specialist (university friend).Specialist argued that AMA only stand for GPs and GP argued that AMA stands only for specialists!!!
Reasons given were simply baseless.I agree from previous comments that uniting medicos is difficult. Most of the members can’t see what AMA does. Most of the councillors give their time generously.
Therefore I urge all those colleagues who are not members please join and support to carry on the good work the AMA does to defend our great profession in most challenging times.
AMA also needs to address people’s grievances and concerns at grassroots level.
Long live AMA – another 100 years.

“Specialist argued that AMA only stand for GPs and GP argued that AMA stands only for specialists!!! ” This is one of the key factors – there is no common set of issues for all Australian medical practitioners. Hence the need for the complex AMA structure – there is potentially a place for everyone. The real challenge is to make it work both ways – the organisation needs to be able to represent individuals and their local circumstances, but also to speak for “the profession” (assuming this is possible). If anyone has suggestions on how this can be done, please bring them forward! One thing the AMA DOES do, however, is to publicly promote public health issues – including obesity, indigenous health, alcohol misuse, smoking (plain packaging) – I see no other health profession’s organisation coming out in this way. As far as the issue of same-sex marriage goes, I support the AMA president’s statements and I appplaud him for supporting human rights in this way.

DITs are leaving the AMA because the industrial relations are a joke. I’ve called for help, and it was made it clear the problem was for me alone to deal with. My friends have had similar experiences.

With this year’s EBA, history would tell us that the AMA will again focus on senior staff, leaving juniors with ongoing terrible and unsafe working conditions.
What about the AMA’s beaming pride over the childcare reimbursements last EBA? That was their flagship win, but it can only be claimed in such unusual circumstances as to make it totally pointless.

It has been suggested that the DITs may break off and start their own union. Having the DITs forgotten again may clinch it.

I am having to resign from the AMA as fees are prohibitive for me as a semi-retired part-time GP. There is no longer an appropriate category.This seems to discriminate against part timers, especially senior doctors amd women in the child-bearing years. This is disappointing , as not withstanding difficulties in representing a group with diverse professional interests, it remains very important to have an umbrella organisation, in difficult times. I have indicated that I would be happy to forgo the more costly accoutrements of membership ( hard copy publications) but have had no response from the organisation.

As a former Chairman of AMA Queensland I can say with confidence that the AMA, a bit like the flaky Federal Labor Party,has become so introverted and obsessed with its own politics that it has forgotten the main game which is to represent the Members. Similarly, AMAQ imploded in an orgy of selfish, metrocentric nastiness which alienated many potential Members. The concept of an all-embracing, brother/sisterhood has been squandered by a few individuals hell bent on furthering their own parochial concepts to the detriment of the greater Medical community. Granted the current Federal President has been quite a beacon in an ocean of malevolance. Those about him have a lean and hungry look which in their minds will only be salved by a successful resolution of their self-centred aspirations. We, the Prols, are expected to fund all of this. Those who purport to run the AMA just don’t get it. Bill Boyd, Mackay, Queensland

I dropped out of membership as a registrar. My reasons were:
a. At the time, registrars were paying the highest rate in number of hours worked to pay the subscription. When I tried to discuss this I was fobbed off and did not feel the paid executive cared.
b. I had previously asked not to get the journal as they were accumulating and I did not find their content useful. Although I was told this would be done, the journal kept on arriving. Again, I did not find people I rang very helpful, or calls were not returned.
c. When a work colleague, a long term member, was the subject of an inquiry after a sentinel event, he felt completely unsupported by the AMA, unlike his medical defence organisation.

As I recall, when I had a dispute with my employer who were bullying me and trying to end my career as a doctor during my internship, the AMA’s response to that was appalling. Their advice led to the health service in question denying everything at which point the AMA dropped me like a hot potato and told me that they wouldn’t give me legal representation and that I should pay for it myself. This in spite of me having clear proof of what was going on. I didn’t want to sue anyone, I just wanted a job, and the AMA did nothing. In the end I was lucky enough to get hired by another health service (and had no further career problems) but the AMA had absolutely no role in my success. They have never achieved anything for me other than minimal rises in pay while in Victoria- moving to NSW gave me far better rights than staying in Victoria ever would have.

Needless to say after internship I have never renewed my membership. And why should I?

Why the hell should I pay for an organisation who claims to “represent” my views when all they do is try to get better deals for hospital VMO’s and screw over the junior doctors, GPs and other doctors? Oh yes, and lobby the government claiming that they are the voice of all doctors.

Maybe if the AMA stopped being so self-interested and actually supported the bulk of the doctors out there (and you know, its own members), people would be interested in membership.

>26,000 members x $1000 membership fees – that’s a whopping 26 Million funding from fees alone. Hard to see the value we get from that, even when considering that the AMA is the last remaining organization still pipping up for doctor’s interests at time.

Currently I’d value their services that I could or would use for myself at < $200, meaning I’d consider membership if it costs up to that much. Once they show that they could provide more value, I’d be prepared to pay more too.

When I was an intern they turned up with a terrible free lunch and told us about a credit card we could get, with no mention of anything else. I joined years later and read the first editorial – a diatribe expounding (and proud of) conservative, paternalistic, closed shop, hypocritical attitudes. Unfortunately 30% of doctors probably have that outlook, so membership may well be representative.

Unfortunately, the AMA is all many of us have. Is it really an option to walk away because we’re disgruntled and too busy, and leave it to the political animals, academics and glory hounds to play with?
The council election processes need reform – well publicised nominations and elections via the internet (as the learned colleges manage to do) so that we don’t have the farce of unopposed elections.
Minutes of committee meetings and supporting documents need to be available online, so that we know what our committees are up to.
Local AMA divisions need to be brought back.
A public on-line forum for debate for members only would help to engage us all.
A few changes like these would help to “de-mushroom” the profession.

Have a look at this year’s Victorian EBA Log of Claims. The reason the AMA has the support of less than half of doctors is because it’s a terrible union that achieves nothing material for its members!!

I am afraid to leave my name because of retribution by those bodies and others singled out for comment, which says a lot and why we need an effective AMA to stand up for us and society in general. I agree with Richard. Ex-doctor would be a good AMA candidate as we are still allowed to work. Could you help and take over from the bureaucrats who run the AMA, who are in with the Boards and not prepared to tackle the issues Richard and I are concerned about? When will the inroads into private practice stop? When will the AMA support and encourage doctors who advocate for our patients? When will the AMA review the Codes of Conduct and take out the generalities and mandatory reporting which only gives more control to those on Boards over us, and where there is no recourse through justice because of collusion and conspiracy or simply bureaucracy between these bodies, agencies of government where decisions are made and accountability lacking. The AMA needs to tackle injustice in Courts, corruption at Board level because of the above, and the problem with the law that allows third parties to make complaints irrespective of the wishes of the patient; and that there are no vetting methods to screen out the vindictive and vexatious complaint, and no definition of vexatious in the legislation; and the Victorian Civil & Administrative Tribunal (VCAT) and at the level of journal editors who feel that to publish a story must be in the political interests of the Journal, rather than to have an honest record of the events so that fairness can prevail somewhere, sometime. We need the AMA to support change to a moral code in society and to tackle the insurance industry which is in a system of interplay with Boards, adopting a supplicant posture when dealing with Boards rather than attacking the injustices in the Law together with the AMA on behalf of the profession and what we stand for; and stop the bullying of doctors by Boards with their self conceived standards of practice and no accountability of their own decisions or system in place to monitor their activities and report on them. Where is the AMA on these issues? The response Karen Price received from the AMA Federal Councillor typifies the lack of moral purpose and awareness required of the AMA that ex-doctor speaks about. A System of Evaluated Decisions is required to bring the decision makers and courts from anecdote to 21st century accountability and prospective evaluation by an independent body of real doctors at least to begin with, and not secretaries of people in jobs for what the job offers instead of for the challenge of advocacy for its members. “